ModifiedUnitedHealthcarePolicy SRST2026T0616N

Epidural Steroid Injections (ESIs) for Spinal Pain

Medical necessity, limitations, coding, and clinical context for epidural steroid injections to manage radicular back pain; applies to UnitedHealthcare coverage determinations and providers performing or requesting ESIs.

Policy Summary

PayerUnitedHealthcare

PolicyEpidural Steroid Injections (ESIs) for Spinal Pain

Policy CodePolicy SRST2026T0616N

Change TypeClinical wording and coding updates

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionVerify current applicable CPT procedure codes and submit prior authorization aligned with policy clinical criteria.

SourceLink

POLICY UPDATE CHANGES

Replaced references to 'Radicular Pain' with 'Radicular Back Pain'.

Removed CPT codes 62323, 64480, and 64483 from applicable codes.

Updated Clinical Evidence, FDA, and References sections to reflect the most current information.

≥4wmin conservative therapy

Max 4ESI sessions / region / yr

≤50%pain relief threshold

Fluoro/CTimaging guidance

Ultrasound

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not medically necessary

06/01/2026policy revision

Coverage and Medical Necessity Criteria

Medical Necessity Criteria

ESIs are proven and medically necessary when ALL of the following are met:

Primary indication: The injection is intended for management of Radicular Back Pain as evidenced by history and physical examination

Conservative therapy: Radicular Back Pain is unresponsive to conservative treatment for ≥ 4 weeks (examples: pharmacotherapy such as NSAIDs or acetaminophen; activity modification; or physical therapy/home exercise)>= 4 weeks

See Definitions for Conservative Therapy

Diagnostic evidence: There is evidence of structural and/or functional nerve root involvement demonstrated by appropriate imaging or electrodiagnostic studies

Imaging/electrodiagnostic documentation required

Image guidance: The injection is performed under fluoroscopic or computed tomography (CT) guidance

Ultrasound guidance is not accepted as medically necessary

Limits and Conditions for Repeat ESIs

Frequency and follow-up criteria:

Annual limit: A maximum of four ESI sessions per region (cervical, thoracic, or lumbosacral) is allowed in a 12-month period starting from the date of the first approved injection; a session is defined as one date of service in which ESIs are performedmax 4 per region per 12 months

Region = cervical, thoracic, or lumbosacral

Conditions for subsequent injections

Option 1: The previous injection resulted in ≤ 50% pain relief or functional improvement for less than 3 months despite reassessment of the individual and the injection site/technique<=50% <3 months
Reassessment of site and technique required
Option 2:

Coverage considerations by indication

Coverage considerations based on evidence and specialty guideline conclusions

Lumbar radicular pain due to disc herniation: Multiple RCTs and systematic reviews demonstrate that lumbar transforaminal and other ESIs provide short-term pain relief for radicular pain from disc herniation and are appropriate as a trial prior to surgical considerationshort-term benefit (1-3 months) documented

Strongest evidence base among indications

Thoracic radiculopathy (disc herniation): Available RCT evidence (limited) suggests thoracic interlaminar ESIs can provide clinical benefit in selected patients with disc-associated thoracic pain; generalizability is limitedselected patients with disc-associated thoracic pain

Evidence limited

Cervical radiculopathy: Evidence is more limited than for lumbar radiculopathy but guideline reviews indicate probable short-term reductions in pain and disability for cervical radiculopathy with ESIs; most data are driven by lumbar studies

Evidence-based coverage rationale

Policy references and evidence summaries used to determine appropriateness of ESIs:

Lumbar radicular pain evidence: Multiple RCTs and NASS review provide high-quality evidence that lumbar ESIs are effective for radicular pain related to lumbar disc herniation for at least 1 month in >50% of patients>=1 RCTs demonstrating short-term benefit

NASS and RCT evidence support short-term effectiveness

Use in low back pain without radiculopathy: AANS/CNS states the literature fails to support lumbar epidural injections for long-term relief of chronic back pain without radiculopathy and provides limited support for short-term relief in selected patients

AANS/CNS 2014 position

Caudal and interlaminar ESIs for low back pain: NASS finds insufficient evidence to recommend for or against caudal and interlaminar ESIs for low back pain

NASS 2020 guidance

Contraindications to epidural steroid injections (ESIs) include active conditions that increase procedural risk or indicate alternate management. Key contraindications listed in the policy are: spinal neoplasm, rapidly progressing neurological deficit, and epidural abscess. Documentation of these conditions should be reviewed before approving or performing an ESI.

ESIs are not recommended for patients with isolated low back pain who lack significant radicular symptoms. The ACOEM guidance states ESIs are not recommended for acute, subacute, or chronic low back pain in the absence of significant radicular symptoms, and the AHRQ review found limited evidence of benefit for spinal stenosis or nonradicular back pain. Providers should document radicular features before pursuing ESI for low back pain without clear nerve-root involvement.

Published guidance does not support the use of lumbar epidural injections for long-term relief of chronic back pain when radiculopathy is absent. The AANS/CNS 2014 joint guideline states the literature fails to support lumbar epidural injections for long-term relief of chronic back pain without radiculopathy and offers only limited support for short-term relief in selected patients.

The policy identifies certain technique and indication scenarios as unproven or not medically necessary. Specifically, the use of ultrasound guidance for ESIs is listed as unproven/not medically necessary, and ESIs performed for spinal indications other than radicular back pain (those not described as covered indications) are likewise considered unproven/not medically necessary due to insufficient evidence.

For low back pain that is nonradicular (no dermatomal radiation or imaging evidence of nerve-root compression), the evidence does not support ESIs for sustained long-term relief. AHRQ concluded benefits for nonradicular back pain and spinal stenosis are limited and not sustained, and ACOEM does not recommend ESIs in the absence of significant radicular symptoms.

Lumbar epidural injections intended to provide long-term relief for chronic back pain without radiculopathy are not supported by the published medical literature and would be considered not medically necessary. The AANS/CNS guideline update emphasizes lack of evidence for sustained benefit in this population.

Applicable Procedure and Diagnosis Codes

Applicable CPT/Procedure CodesCPT

62320	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance.
62321	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (i.e., fluoroscopy or CT).
62322	Injection(s), of diagnostic or therapeutic substance(s), interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance.
64479	Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level.
64484	Injection(s), anesthetic agent(s) and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Applicable Diagnosis CodesICD-10

M47.20	Other spondylosis with radiculopathy, site unspecified.
M47.22	Other spondylosis with radiculopathy, cervical region.
M51.15	Intervertebral disc disorders with radiculopathy, thoracolumbar region.
M54.10	Radiculopathy, site unspecified.
M54.16	Radiculopathy, lumbar region.
M54.31	Sciatica, right side.
G54.2	Cervical root disorders, not elsewhere classified.
G54.4	Lumbosacral root disorders, not elsewhere classified.
S14.2XXA	Injury of nerve root of cervical spine, initial encounter.
S34.21XA	Injury of nerve root of lumbar spine, initial encounter.

Removed CPT CodesCPTNot Covered

62323	CPT code removed
64480	CPT code removed
64483	CPT code removed

Annual ESI session limit — inv-14

LimitMaximum of four ESI sessions per region per 12-month period (a year is the 12‑month period starting from the date of service of the first approved injection).

Session definitionA session is defined as one date of service on which ESIs are performed.

Region definitionRegion = cervical, thoracic, or lumbosacral.

Subsequent injection conditionSubsequent ESIs may be provided only if radicular back pain has returned and/or function deteriorated, plus meeting the relief/duration criteria.

Timing ruleYear measured from first approved injection date (12‑month rolling period).

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization & Coding

Prior Authorization Required: Prior authorization is required for the listed epidural steroid injection (ESI) procedure codes and for repeated injections that exceed guideline-recommended frequencies or when clinical criteria are not met. Claims must align with the policy's clinical criteria, conservative-treatment requirements, and coding guidance.

Verify applicable CPT codes prior to authorization requests.
Prior authorization may be required for injections requested more frequently than guideline-recommended intervals (see frequency limits).

Documentation Required

Required Clinical Documentation

Required Clinical Documentation: Provide documentation that supports radicular back pain and medical necessity. Documentation must include history and physical exam findings consistent with radicular back pain, evidence of structural and/or functional nerve root involvement (imaging or electrodiagnostic studies), the conservative therapies tried and duration, and procedure details including imaging guidance.

Key Definitions

Conservative Therapy — inv-28

Core componentsMedication (e.g., NSAIDs or analgesics) plus physical therapy or home exercise.

Additional optionsSpinal manipulation therapy or cognitive behavioral therapy as appropriate to the individual's presentation.

IndividualizationCombination and choice of interventions based on the individual's specific presentation, physical findings, and imaging results.

Epidural Steroid Injections — inv-29

DefinitionNonsurgical injections of corticosteroid (and typically local anesthetic) into the epidural space intended to relieve radiculopathy from disc herniation or degenerative vertebral changes.

GoalRelieve pain, improve function, and improve quality of life.

Required Trials and Waiting Periods Before ESI

Must be attempted and documented prior to ESI

Conservative therapy requirement: At least 4 weeks of conservative therapy must be attempted and documented prior to ESI (examples: NSAIDs or acetaminophen, activity modification, or physical therapy/home exercise)>= 4 weeks

Conservative Therapy as defined in Definitions

Trial of conservative therapy prior to ESI when indicated

Trial before ESI for acute/subacute radicular pain: Guidelines recommend trying conservative measures (e.g., NSAID trial and a waiting period or physical therapy) for at least approximately 3 weeks before considering ESI for acute or subacute radicular paine.g., >=3 weeks

ACOEM recommends at least a 3-week waiting period after NSAID trial

Limits on Number and Timing of Epidural Steroid Injections

Epidural Steroid Injections — inv-38

Maximum per regionMaximum of four ESI sessions per region per 12‑month period (region = cervical, thoracic, or lumbosacral).

Session and year definitionsA session = one date of service; a year = 12‑month period starting from date of first approved injection.

Applies regardless of level/sideLimit applies per region regardless of level, location, or side treated.

Epidural steroid injection (therapeutic phase) — inv-39

Annual frequency capTherapeutic epidural steroid injections should not exceed 4 per year per region.

Interval guidanceSuggested interval between therapeutic injections is 2½ to 3 months or longer when >50% relief is obtained for that period.

Imaging and Guidance Requirements for ESIs

Documentation Required

Fluoroscopy or CT required for covered ESIs

Covered ESIs (interlaminar or transforaminal) must be performed under fluoroscopic or computed tomography guidance; ultrasound guidance is not accepted as medically necessary.

Policy requires fluoroscopic or CT guidance for covered ESIs
Ultrasound guidance is listed as unproven and not medically necessary

Documentation Required

Fluoroscopy/contrast confirmation required for transforaminal ESIs

For transforaminal epidural injections, confirm needle position and contrast spread with fluoroscopy (or CT) before injecting therapeutic substances; use of image guidance and contrast confirmation is required for TFESI.

Transforaminal injections should include image guidance to confirm needle position and contrast spread prior to therapeutic injection

Documentation Required

Services Considered Not Medically Necessary / Unproven

Not covered under this policy are procedures and indications that lack sufficient evidence of efficacy. This includes ultrasound-guided ESIs, which the policy lists as unproven/not medically necessary, and ESIs for spinal indications other than radicular back pain (for example, primary nonradicular low back pain), which are likewise considered not medically necessary.

Policy Summary

PayerUnitedHealthcare

PolicyEpidural Steroid Injections (ESIs) for Spinal Pain

Policy CodePolicy SRST2026T0616N

Change TypeClinical wording and coding updates

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionVerify current applicable CPT procedure codes and submit prior authorization aligned with policy clinical criteria.

SourceLink

On This Page

The previous injection resulted in ≥ 50% pain relief or functional improvement for 3 or more months

Documented relief duration required

short-term pain/disability improvement possible

Limited direct cervical data

Spinal stenosis and nonradicular low back pain: Systematic reviews and guideline bodies note little to no sustained benefit of ESIs for spinal stenosis or nonradicular axial low back pain; several guidelines do not recommend ESIs for low back pain without significant radicular symptomsabsence of radicular symptoms or diagnosis of stenosis

Not recommended or low benefit per multiple guidelines

Efficacy for lumbar spinal stenosis (LSS): WFNS and NASS note short- to intermediate-term benefits of ESIs for symptomatic LSS but conflicting or poor-quality evidence for long-term efficacy; multiple-injection regimens may produce longer relief though evidence is limited

WFNS 2020; NASS reviews

FDA safety considerations: The FDA notes corticosteroids are not approved for epidural administration, warns that epidural corticosteroid injections have not established safety/effectiveness for this use, and identifies rare but serious adverse events (vision loss, stroke, paralysis, death) that should be discussed with patients

Informed consent should include FDA-stated risks

History and physical exam documenting radicular back pain (dermatomal distribution and nerve root pattern).
Imaging (MRI/CT) or electrodiagnostic evidence of nerve root involvement.
Records of conservative therapy attempted and duration (see conservative treatment requirement).
Procedure note confirming use of fluoroscopic or CT guidance.

Documentation Required

Conservative Treatment Requirements

Conservative Therapy Requirement: Conservative therapies must be attempted and documented prior to ESI for most nonsevere indications. Typical conservative measures include pharmacotherapy (NSAIDs, acetaminophen), activity modification, and physical therapy or home exercise programs. For lumbar spinal stenosis (LSS), a trial of therapeutic exercise or conservative care for at least 3 weeks is recommended before interventions; if symptoms do not improve after approximately 3 months, surgery should be considered.

Document at least 4 weeks of conservative treatment for radicular back pain prior to ESI, unless clinical circumstances justify earlier intervention.
For LSS, document a trial of therapeutic exercise or conservative care for ≥3 weeks; consider limits on repeat injections if relief is <3 months.

Billing Rule

Frequency Limits & Repeat Injections

Frequency Limits Guidance: Limit therapeutic epidural injections to the suggested frequency noted in specialty guidance. Repeating injections more frequently than recommended or exceeding the suggested annual maximum may trigger additional review or denial.

Suggested therapeutic frequency: generally 2½ to 3 months or longer between injections when >50% relief is achieved, not exceeding 4 injections per year per region.
Requests for injections more frequently than guideline intervals or exceeding 4 per year per region require justification and may require prior authorization.

Note

FDA Safety Information

FDA Safety Considerations: FDA communications note that the effectiveness and safety of epidural administration of corticosteroids have not been established and that rare but serious adverse events have been reported. These considerations may affect clinical decision-making and coverage determinations.

The FDA has not approved corticosteroids for epidural administration and has required label warnings about rare but serious neurologic events (e.g., loss of vision, stroke, paralysis, death).
Discuss benefits and risks with patients and document informed consent as appropriate; FDA safety information may be considered during utilization review.

Typical useUsed as a therapeutic intervention for radicular back pain; performed via interlaminar, transforaminal, or caudal approaches.

Radicular Back Pain — inv-30

DefinitionPain that radiates from the spine into the extremity along the course of a spinal nerve root (follows a dermatome) and is associated with nerve root irritation, e.g., from disc herniation.

Evidence noteMultiple RCTs and guideline reviews (NASS) support use of ESIs for lumbar radicular pain, particularly due to disc herniation, for short‑term benefit.

Policy updateTerm usage updated in policy to 'Radicular Back Pain' to specify pain radiating into the extremity along a dermatome.

Nonradicular Back Pain — inv-31

DefinitionPain that does not radiate along a dermatome and for which imaging and clinical exam do not demonstrate spinal nerve root compression.

Clinical implicationESIs are generally not recommended for nonradicular back pain as long‑term benefit is not supported by the literature (AANS/CNS).

Distinguishing featureAbsence of dermatomal radiation and lack of imaging/electrodiagnostic evidence of nerve root involvement.

Lumbar radiculopathy (disc herniation) — inv-32

DefinitionRadicular pain due to lumbar disc herniation causing irritation/compression of a lumbar nerve root (lumbar radiculopathy).

Evidence supportMultiple RCTs and meta-analyses (including transforaminal ESI studies) show short‑term pain relief and functional benefit for this condition.

Clinical roleESI may be used as a trial prior to surgical consideration for radicular pain from disc herniation.

Axial spine pain — inv-33

DefinitionAxial spine pain refers to pain localized to the spine (nonradicular), including thoracic axial pain, without dermatomal radiation.

Evidence noteNetwork meta-analysis found little to no difference in pain relief from ESIs for chronic axial spine pain compared with sham in many studies.

Clinical implicationESIs are less supported for axial spine pain; guideline evidence does not show convincing long‑term benefit.

Radicular Back Pain — inv-34 (term usage update)

Definition clarificationRadicular Back Pain — pain radiating from the spine into the extremity along a dermatome corresponding to an irritated nerve root; policy language updated to use this term consistently.

RationaleUsed throughout policy to align indications, evidence summaries, and coverage criteria concerning nerve‑root–related pain.

Related guidanceCoverage decisions and frequency limits apply specifically to radicular back pain presentations as defined here.

Document trial of conservative therapy and duration when seeking injections for LSS

Conservative therapy documentation for LSS: For lumbar spinal stenosis (LSS), document a trial of conservative therapy or at least 3 weeks of therapeutic exercise prior to injections; consider surgical referral if clinical condition does not change after 3 months>= 3 weeks (exercise)

If relief < 3 months after injection, further injections are not recommended

Repeat criteriaRepeat therapeutic injections require documentation of relief (percentage and duration) and reassessment of the individual and technique.

Epidural steroid injections for lumbar spinal stenosis — inv-40

LSS-specific recommendationFor lumbar spinal stenosis (LSS), proceeding with further epidural injections is not recommended for patients whose symptomatic relief after an injection lasted less than 3 months.

Conservative-firstWFNS recommends at least 3 weeks of therapeutic exercise as initial conservative care for nonsevere LSS; consider surgery if no improvement after 3 months.

Evidence contextLiterature supports short‑ to intermediate‑term benefits of ESIs for symptomatic LSS, but inclusion of steroid provides no added benefit over local anesthetic alone.

Use fluoroscopy or CT for transforaminal ESIs (cervical and often lumbar)

Fluoroscopy or CT guidance is recommended for transforaminal ESIs in cervical radiculopathy and often for lumbar TFESI; ensure documentation of imaging guidance when submitting authorization or claims.

NASS: transforaminal ESIs using fluoroscopic or CT guidance may be considered for cervical radiculopathy
Document the imaging modality used (fluoroscopy or CT) in the record and authorization request